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Systematic Review

What Is the Optimal Exercise Prescription for Patients With

Dilated Cardiomyopathy in Cardiac Rehabilitation?
Yong Gon Seo, PhD; Mi Ja Jang, MS, RN; Ga Yeon Lee, PhD; Eun Seok Jeon, PhD;
Won Hah Park, PhD; Ji Dong Sung, PhD
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Purpose: Dilated cardiomyopathy (DCM) is 1 of the major defined as a dilated left ventricle (>5.5 cm) with an ejection
causes of advanced heart failure. However, relatively little is fraction <45%.2 The clinical course of DCM frequently in-
known about the effects of exercise specifically in patients with volves ventricular arrhythmias resulting in sudden cardiac
DCM. This purpose of this literature review was to identify opti- death.3 Several treatment options including medical ther-
mal exercise training programming for patients with DCM. apy and implantable cardioverter defibrillators are used
Methods: A systematic review was conducted by 3 clinical spe- to reduce symptoms and prevent sudden cardiac death.
cialists and the level of evidence of each study was rated using Medical therapy is the first approach to improve symptoms
Sackett’s levels of evidence. Multiple databases (PubMed Cen- and reduce mortality in patients with DCM, and includes
tral, EMBASE, and EBSCO) were searched with the inclusion angiotensin II receptor blockers and β-blockers.4
criteria of articles published in English. Exercise therapy is 1 of the most important interven-
Results: A total of 4544 studies were identified using the search tion options to improve cardiopulmonary function and
strategy, of which 4 were included in our systematic review. The quality of life (QOL) in cardiac patients, but is common-
exercise frequency of the reviewed studies ranged from 3 to 5 ly underutilized.5-8 Furthermore, optimal exercise inten-
times/wk, and exercise intensity was prescribed within a range sity is considered an important factor for conducting safe
from 50% to 80% of oxygen uptake reserve. Exercise time was and effective exercise training.9 Current recommendations
as high as 45 min by the final month of the exercise prescrip- for determining target exercise intensity are based on the
tion. Exercise type was mainly aerobic exercise and resistance FITT-VP (frequency, intensity, time, and type—volume and
training. The average improvement of exercise capacity was progression) principle.10 Based on these recommendations,
19.5% in reviewed articles. Quality of life also improved after exercise professionals should consider current health status
intervention. of a patient, cardiorespiratory fitness level, risk stratifica-
Conclusions: According to this systematic review of the liter- tion, and comorbidities when prescribing exercise intensity,
ature, data related to exercise therapy specifically for patients frequency, time, and type.
with DCM are scarce and exercise interventions in articles re- Exercise training may be a useful intervention for pa-
viewed were prescribed differently using the FITT (frequency, tients with DCM, but currently there is a lack of sufficient
intensity, time, and type) principle. Exercise intensity tailored to clinical data regarding the physiological response to exer-
individual exercise capacity should be used for optimal exercise cise and an understanding of the effect of exercise training
prescriptions that are safe and efficacious in patients with DCM. relative to other cardiac diseases. The response to exercise
in patients with idiopathic DCM has specific characteris-
Key Words: cardiac rehabilitation • dilated cardiomyopathy •
tics of severe depression of systolic and diastolic function
exercise prescription
with well-preserved exercise capacity.11 In addition, several
studies have considered exercise intervention for patients
D ilated cardiomyopathy (DCM) is the most common
cardiomyopathy and is characterized by left ventric-
ular dilation and left ventricular systolic dysfunction.1
with DCM and demonstrated that exercise therapy is a safe
and effective approach for improving exercise capacity and
Based on cardiac MRI and echocardiography, DCM can be QOL in these patients.2,12-14 However, the prescriptions for
exercise reported in these studies were variable. Thus, the
Author Affiliations: Division of Sports Medicine, Department of Orthopedic
overall goal of this study was to identify an optimal exer-
Surgery (Mr Seo and Dr Park), Heart Stroke and Vascular Institute, cise prescription for individuals with DCM. To that end, we
Department of Nursing, Cardiac Center, Rehabilitation & Prevention Center performed a systematic review of the literature.
(Ms Jang), Cardiac Center, Heart Stroke and Vascular Institute (Drs Lee
and Jeon), and Rehabilitation and Prevention Center, Heart Stroke and
Vascular Institute (Dr Sung), Samsung Medical Center, Seoul, South Korea; METHODS
Sungkyunkwan University School of Medicine, Seoul, South Korea (Mr Seo,
Ms Jang, and Drs Lee, Jeon, Park, and Sung).
A systematic review of the literature was conducted using
All authors have read and approved the article.
PubMed, Cochrane Central Register of Controlled Trials,
The authors declare no conflicts of interest. EMBASE, and EBSCO databases. The search keywords
Correspondence: Ji Dong Sung, PhD, Division of Cardiology, Department were “dilated cardiomyopathy” and “exercise therapy.”
of Internal Medicine, Sungkyunkwan University School of Medicine, To perform a more comprehensive search, we also used
Rehabilitation & Prevention Center, Heart Stroke & Vascular Institute, the terms “physical therapy,” “exercise intervention,”
Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, South “exercise,” “exercise training,” and “cardiac rehabilita-
Korea (
tion” in place of exercise therapy (Table 1). The search
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. included articles published between 1980 and 2017, and
DOI: 10.1097/HCR.0000000000000382 all articles identified in the search were evaluated. The Optimal Exercise Prescription for Dilated Cardiomyopathy 235

Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Table 1 vention, we extracted data related to exercise frequency,
intensity, time, and type. To evaluate functional outcome
Electronic Search Terms and Number of Articles Identified
parameters, we also extracted data related to exercise test
by Database
mode using a questionnaire and special evaluation for
PubMed CENTRAL EMBASE EBSCO checking function (Table 2). All articles were rated using
DCM and exercise therapy 539 159 805 901 Sackett’s Level of Evidence scale,15 from the strongest (rat-
DCM and physical therapy 242 36 458 2
ing = 1) to weakest (rating = 5) (Table 3).
DCM and exercise intervention 18 11 47 778
DCM and exercise training 76 19 113 4
DCM and cardiac rehabilitation 150 8 176 2
Total articles 1025 233 1599 1687 LITERATURE SEARCH
Abbreviations: CENTRAL, Cochrane Central Register of Controlled Trials; DCM, dilated The search strategy initially yielded 4544 articles and du-
cardiomyopathy; EMBASE, Excerpta Medica dataBASE. plicate articles were discarded. A total of 19 articles were
subjected to a full-text review, from which we excluded
15 studies comprising 2 case reports, 1 animal study, 1
selection criteria for eligible interventions were any study nonrandomized control trial study, 8 studies that included
that described the use of exercise therapy only for the treat- non-DCM patients, and 3 studies based on the same patient
ment of DCM in humans. Two authors (Y.G.S. and G.Y.L.) group (Figure).
independently reviewed the studies identified by the search
and extracted articles that met the inclusion criteria. First, BASELINE NYHA CLASSIFICATION
all articles were originally reviewed by title. A discussion The New York Heart Association (NYHA) classification is
for determining whether an article was to be included was commonly used as a method for functional classification in
held when there was disagreement between the 2 reviewers. patients with cardiac disease. The functional status is cat-
In cases where an agreement could not be reached, a third egorized by 4 classifications with high numbers indicating
author (J.D.S.) reviewed the title to determine whether it more severe limitation of physical function. The NYHA
should be included. The same procedure was used to review classification of study patients was I and II in 2 studies,
abstracts and again for review of the full text of a study to while the other 2 studies by Mehani12 and Holloway et al2
determine inclusion or not. Five titles and 8 abstracts were included 9 and 4 patients with NYHA classification III, re-
reviewed by a third author for inclusion in this review. spectively. Only the study by Stolen et al13 described the
change of NYHA classification after intervention with an
OUTCOMES OF INTEREST AND LEVEL OF QUALITY improvement from 1.6 ± 0.5 to 1.2 ± 0.4.
The extracted information included study design, level of
evidence, subject characteristics, type of exercise therapy MAXIMAL OXYGEN UPTAKE
intervention, functional outcomes, and other notable find- In 3 of the studies, symptom-limited exercise testing was
ings. With respect to the type of exercise therapy inter- performed using an electrically-braked cycle ergometer. The

Table 2
Summary of Included Articles
Study Design Subject Characteristics Exercise Interventiona Outcome Measures Type of Training
Mehani Prospective RCT (n = 40): Age: 50-65 y F: 3×/wk for aerobic training V̇O2peak: 16.1 ± 3.65 to 21.08 ± Center-based
(2013)12 n = 15 exercise group; >8 mo history of DCM; I: 55%-80% of HRR 5.47 mL/kg/min supervised
n = 15 control group; n clinically stable for T: Up to 45 min at 7 mo EF: 33.09% ± 4.77% to 48.93% exercise
= 10 dropped out >3 mo T: Aerobic training (interval) ± 8.38% intervention
KCCQ: functional score (75.01%);
clinical score (129.28%)
Holloway et al Prospective study (n = 15) Age: 59 ± 2 y F: 7×/wk for aerobic training 6-min walk test: 469 ± 21 m to Home-based
(2012)2 Stable on medical I: 70%-80% of HRmax or RPE 508 ± 25 m exercise
therapy for >6 mo 12-14 EF: 39% ± 3% to 44% ± 3% intervention
T: 20 min for 2 mo MLHFQ: 28%
T: Aerobic training
Stolen et al Prospective RCT (n = 20): Age: 55 ± 8 y F: 3×/wk for aerobic exercise V̇O2peak: 19.4 ± 4.1 to 24.6 ± Center-based
(2003)13 n = 9 exercise group; n Clinically stable under I: 50%-70% of V̇O2peak 5.2 mL/kg/min supervised
= 7 control group; n = active medical T: 45 min for 5 mo EF: 33.3% ± 8.3% to 38.6% exercise
4 dropped out treatment T: Aerobic and resistance ± 8.5% intervention
training Short-form 36: general health,
pain, vitality improved
Beer et al Prospective study (n = 24): Age: 53 ± 12 y F: 5×/wk for aerobic training V̇O2peak: 21.7 ± 3.8 to 25.3 ± Center-based
(2008)14 n = 12 exercise group; Reduced ejection fraction I: 60%-80% of V̇O2R or RPE 5.2 mL/kg/min supervised
n = 12 control group <40% and absence 13-15 EF: 30% ± 15% to 37% ± 15% exercise
of coronary artery T: 45 min for 2 mo intervention
disease T: Aerobic training
Abbreviations: DCM, dilated cardiomyopathy; EF, ejection fraction; HRR, heart rate reserve; HRmax, maximal heart rate; KCCQ, Kansas City Cardiomyopathy Questionnaire; RCT, randomized
control trial; RPE, rating of perceived exertion; MLHFQ: Minnesota Living With Heart Failure Questionnaire; V̇O2, oxygen uptake; V̇O2R, oxygen uptake reserve.
Reported as FITT: frequency (F), intensity (I), time (T), and type (T).

236 Journal of Cardiopulmonary Rehabilitation and Prevention 2019;39:235-240

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Table 3 Wasserman protocol. These studies reported improvements
Evidence Levels According to Sackett’s Levels of Evidencea
in exercise capacity resulting from exercise training from
16.1 ± 3.65 mL/kg/min (5.6 METs) to 21.08 ± 5.47 mL/kg/
Number of Included min (7.6 METs) (26%)12 and from 21.7 ± 3.8 mL/kg/min
Levels of Evidence Studies (7.3 METs) to 25.3 ± 5.2 mL/kg/min (8.7 METs) (17%).14
1A Systematic review of RCTs — The average exercise capacity in the included studies was 6.5
1B RCT with narrow CI — METs before intervention and 8.3 METs after intervention.
1C All or none case series — These values are lower values compared with average values
2A Systematic review cohort studies —
for 50 age-matched healthy adults.16
2B Cohort study/low-quality RCT 3
2C Outcomes research 1
3A Systematic review of case-controlled studies —
An exercise prescription consists of exercise frequency, intensi-
ty, time, type, and a recommendation on whether supervision
3B Case-controlled study —
is needed. Exercise frequency ranged from 3 to 5 times/wk in
4 Case series, poor cohort case controlled —
the 4 studies we evaluated. The initial exercise intensity was
5 Expert opinion —
50% to 55% of the functional capacity determined in each
Abbreviation: RCTs, randomized controlled trials. study and was progressively increased over the intervention
Sackett’s levels of evidence modified according to Burns et al. 15 period of 2 to 7 mo to achieve a goal of 80% of peak exercise
intensity in 3 studies, and 70% in 1 study,13 which used an
initial exercise intensity of 50% of peak V̇O2 and progressively
specific testing protocol was not described in any of the in- increased during the 5-mo period. Three of the studies utilized
cluded articles. In the study by Holloway et al,2 a 6-min walk aerobic exercise as the main exercise type, while Stolen et al13
test (6MWT) was used as the testing mode for estimating ex- also prescribed resistance training twice/week beginning after
ercise capacity. Exercise capacity improved in all studies in 4 wk of aerobic exercise. A study by Mehani12 used interval
patients who received exercise training. Although the train- aerobic circuit training using a treadmill, cycle ergometer and
ing periods varied, improvement of maximal oxygen uptake a Stairmaster (Life Fitness) with initial exercise intensity of
(V̇O2max) ranged between 8% and 27% in patients receiving 55% of heart rate reserve (HRR) and increasing to 80% at
exercise training compared with patients not receiving ex- the end of the seventh month. The maximum exercise time
ercise training. In the study by Stolen et al,13 symptom-lim- was 45 min in 3 studies and 20 min in 1 study2 that prescribed
ited, incremental cycle ergometer testing with continuous exercise intensity to achieve a training heart rate between
respiratory gas exchange analysis was used and reported 70% and 80% of the initial exercise test maximum heart rate.
the highest improvement in exercise capacity (27%; mean The study duration ranged from 2 to 7 mo, but 1 study14 used
± SD V̇O2max= 19.4 ± 4.1 mL/kg/min; 6.7 metabolic equiv- a 2-mo training period and determined clinical outcomes af-
alents [METs]) pre-training versus 24.6 ± 5.2 mL/kg/min ter 2 and 8 mo from baseline. The exercise intervention was
(8.5 METs) post-training. The increase in 6MWT distance conducted with supervision in 3 studies, while patients in the
increased from 469 ± 21 m before exercise training to 508 Holloway et al2 study were prescribed a home-based exercise
± 25 m (8% increase) after exercise training was reported program without direct supervision.
by Holloway et al.2 The remaining 2 studies12,14 both used
an electrically braked cycle ergometer for exercise testing; 1
used an individualized ramp protocol and the other used the
Several of the included studies used a questionnaire to
evaluate QOL after an exercise intervention. Specifically,
Mehani12 used the Kansas City Cardiomyopathy Question-
naire (KCCQ), a disease-specific instrument for evaluating
QOL in patients with chronic heart failure, and reported
a statistically significant difference between both groups in
the functional score (75.0%) and clinical summary scores
(129.3%). Holloway et al2 used the Minnesota Living With
Heart Failure Questionnaire (MLHFQ), which was de-
signed to measure physical and emotional dimensions of
QOL for heart failure. A decreased score after an interven-
tion means an improvement in physical or emotional state,
and this reported an improvement of 28% compared with
baseline in patients who received exercise training, with an
average post-intervention score of 17 ± 3 versus a pre-in-
tervention score of 26 ± 5. Stolen et al13 used the RAND
36-item health survey (SF-36), which measures generic
health-related QOL and a higher score denotes improve-
ment in QOL, and the results demonstrated an improve-
ment in general health, pain, and vitality compared with
baseline in patients who received exercise training.

Proper exercise intensity is important to ensure both the
safety and effectiveness of an exercise intervention. Exercise
Figure. Flowchart of articles included in this literature review. DCM indi- training can improve exercise capacity and QOL while re-
cates dilated cardiomyopathy; EMBASE, Excerpta Medica dataBASE. ducing cardiac mortality in several different types of cardiac
patients.6-8 To help provide insight into the role of exercise Optimal Exercise Prescription for Dilated Cardiomyopathy 237

Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
therapy for exercise professionals in patients with DCM, improvement in exercise capacity was reported by Mehani12
we systematically reviewed 4 published articles in which ex- (26%; mean 4.5-5.4 METs). Previous studies on the effects
ercise therapy was conducted specifically for patients with of exercise in patients with heart failure have reported a
DCM. similar range (0%-27%) in the improvement of exercise ca-
pacity.27 Based on a previous meta-analysis,28 the difference
NYHA CLASSIFICATION in the improvement in exercise capacity is dependent on the
The NYHA classification scheme is commonly used to de- intensity of exercise intervention, age of the patient, gender,
fine the level of function in patients with cardiac disease and and baseline V̇O2max.
is based on symptoms during physical activity.17 Important-
ly, aerobic exercise in patients with heart failure can lead EXERCISE PRESCRIPTION
to a 0.5 improvement in NYHA functional class.18 Among Many studies24,29 have reported that physical inactivity
the articles included in our systematic review, the highest and low exercise capacity are associated with the develop-
NYHA classification prior to intervention was III. In 1 of ment of cardiovascular disease. Likewise, exercise therapy
the reviewed studies, the NYHA class improved from 1.6 has been shown to improve exercise capacity and QOL in
± 0.5 to 1.2 ± 0.5 (change: −18.5%) after an exercise in- patients with cardiac disease.6,7,9 Individualization of the
tervention, while there was a minimal change in the control exercise prescription for patients with DCM is essential
group from 1.2 ± 0.4 to 1.1 ± 0.4 (change: −4.8%).13 Al- for obtaining the maximal benefit. Such individualization
though the correlation between the improvement in NYHA can be achieved by considering a patient’s current exercise
functional class and exercise capacity in that study was habits, exercise capacity, and other individual factors.9 The
not very high, the exercise capacity in the training group principle of an exercise prescription is based on the FITT
was significantly improved from 19.4 ± 4.1 to 24.6 ± principle: frequency (F), intensity (I), time (T), and type (T)
5.2 mL/kg/min (change: +27.2%) compared with the con- of exercise.30,31 In the studies we reviewed, the frequency
trol group (change: +4.2%). A previous study19 reported of exercise ranged from 3 to 5 times/wk, consistent with
that NYHA functional class correlated inversely with 6-min the general exercise recommendations for healthy adults,32
walk distance, and thus we speculated the possibility that which also suggest combining moderate and vigorous in-
an improvement in exercise capacity was the main factor tensity exercise.
behind the change in NYHA class in the study groups. Fur- Based on the reviewed studies, the appropriate intensity
ther studies will be needed to verify these results. of aerobic exercise for patients with DCM was like that
Most patients with DCM in the reviewed studies were recommended in previous studies33-36 conducted with pa-
NYHA classes II and III. In these patients, exercise inter- tients with other forms of heart failure. Aerobic exercise
vention was conducted safely without adverse events during intensity can be determined using 1 of several commonly
the intervention period, supporting the idea that exercise used equations based on %HRR, %V̇O2R, or %maximal
intervention in this patient population is relatively safe. heart rate. A graded exercise test is recommended for eval-
However, extra care should be taken when prescribing ex- uating exercise capacity before and after exercise interven-
ercise training to NYHA class IV patients to prevent any tion. Most of the studies we reviewed determined exercise
complications because the studies reviewed did not provide intensity based on the %V̇O2R and %HRmax data. Specifi-
recommendations for these patients. cally, the initial exercise intensity prescribed was generally
as low as 50% of V̇O2peak, representing an optimal moder-
MAXIMAL OXYGEN UPTAKE ate-intensity regimen (40%-60% V̇O2R),21 and increased
Exercise capacity can be precisely measured by V̇O2max during up to 80% V̇O2R, representing vigorous exercise intensity
exercise, which represents the limit of cardiopulmonary used in 1 study.29
function for transporting oxygen to the exercising muscles.20 Current guidelines recommend prescribing a progressive
Exercise capacity can also be expressed in METs, with 1 increase in exercise intensity to achieve a safe and effective
MET representing energy expenditure with a person in the intervention.37 In general, %HRR and %V̇O2R parameters
sitting position, and is equal to 3.5 mL/kg/min. METs can be are used to determine exercise intensity; however, the rating
used to describe the intensity of a variety of physical activ- of perceived exertion (RPE) is recommended for patients
ities.21 The intensity of physical activity can be categorized being treated with β-blockers or who have undergone heart
into 3 levels, with light physical activity classified as activity transplantation. The RPE scale ranges from 6 to 20, and an
requiring <3 METs, moderate activity classified as 3 to 6 RPE of 12 to 13 is consistent with moderate intensity, while
METs, and vigorous activity classified as >6 METs.21 Peak an RPE of 14 to 17 is associated with vigorous intensity.31
METs are 1 of the strongest predictors of all-cause mortali- Among the studies we reviewed, 2 mentioned the use of the
ty,22,23 and the increase of a 1 MET for exercise capacity was RPE scale for prescribing exercise intensity using 12 to 14
associated with 13% and 15% reduction of risk in all-cause and 13 to 15 ranges, respectively.2,14
and cardiovascular mortality, respectively. Additionally, pa- Three of the studies evaluated in this review prescribed
tients with a maximal aerobic capacity of ≥7.9 METs had aerobic exercise for a total of 45 min/session, while Hol-
a lower risk of all-cause and cardiovascular mortality com- loway et al2 prescribed 20 min of cycling-based exercise/
pared with those with an aerobic capacity of <7.9 METs.24 day. The prescription for the duration of exercise in pa-
In this systematic review, the baseline exercise capacity of tients with chronic heart failure is usually 20 to 30 min at
participants was much lower than that of an age-matched the desired intensity,36 while the duration of target aero-
general healthy population. For example, the lowest exer- bic exercise is generally 20 to 60 min/session for cardiac
cise capacity among participants in the study by Mehani12 patients.37 Ultimately, the prescription for the initial du-
was 3.6 METs. Although the correlation between NYHA ration of exercise should vary according to the individual
functional class and exercise capacity was not significant, current state of health of the patient and should also con-
several studies have demonstrated a significant difference in sider previous levels of physical activity and baseline exer-
exercise capacity between NYHA functional classes II and cise capacity. The exercise protocols of the reviewed stud-
III/IV.19,25,26 In the studies evaluated in this review, exercise ies included both continuous and intermittent exercise,
capacity improved between 8% and 27% from baseline in for which the minimum duration of intermittent exercise
patients who received an exercise intervention. The greatest should be at least 10 min.21 Lastly, the total duration of

238 Journal of Cardiopulmonary Rehabilitation and Prevention 2019;39:235-240

Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
an exercise intervention in the reviewed articles was 2 to CONCLUSIONS
7 mo; however, health professionals should adjust the In this systematic review, we evaluated the evidence for
initial prescription for exercise duration according to the optimal exercise therapy in patients with DCM. Overall,
health status of the patients, exercise tolerance, and exer- exercise therapy appeared to be a safe and effective inter-
cise program goals. vention for improving exercise capacity and QOL in pa-
A cycle ergometer is commonly used to assess aero- tients with DCM. An exercise prescription for patients with
bic exercise capacity and was the main exercise modality DCM consisted of exercise frequency, intensity, time, and
used in the reviewed studies. The type of exercise pre- type according to recommendation by ACSM guidelines.
scribed should be determined according to the goal of The different results in reviewed articles resulted from ap-
exercise. In general, both aerobic and strength exercises plication of different exercise intensity and times for each
are recommended for cardiac patients. However, of the article. Therefore, these parameters should be considered
included studies, only Stolen et al13 combined both resis- an important factor in prescribing suitable exercise. Lastly,
tance training and aerobic exercise intervention. Different with respect to developing an exercise prescription for pa-
types of exercise training included aerobic training, resis- tients with DCM, it is important for exercise professionals
tance training, and combined training, all of which are to consider the baseline exercise capacity of the patients,
safe and effective methods for maximizing improvement previous exercise habits, and daily condition when prescrib-
of exercise capacity.38 Furthermore, resistance training ing initial exercise intensity and adjusting day-to-day train-
for cardiac patients is recommended as a way to com- ing. Furthermore, large trials are needed to define optimal
plement aerobic training, and provides additional bene- exercise intervention for patients with DCM considering
fits with respect to muscular strength and endurance.39,40 the insufficiency of data from 4 reviewed studies.
In the study by Stolen et al,13 the training prescription
consisted of a high number of repetitions (10-15) in 2
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